What are common complex pediatric gastroenterology, hepatology, and nutrition cases for 2nd-year pediatric residents?

Common Complex Pediatric Gastroenterology, Hepatology, and Nutrition Cases for 2nd-Year Pediatric Residents

Second-year pediatric residents should master the evaluation and management of inflammatory bowel disease (IBD), chronic liver disease requiring transplant evaluation, gastroesophageal reflux disease (GERD), eosinophilic esophagitis (EoE), and malnutrition in chronic GI conditions—these represent the most clinically significant and complex cases that directly impact morbidity, mortality, and quality of life.

Inflammatory Bowel Disease (IBD)

IBD in children presents with more extensive disease phenotype and rapid early progression compared to adult-onset disease, requiring aggressive nutritional support and specialized transition planning. 1

Key Clinical Features

• Children with Crohn's disease demonstrate higher utilization of exclusive enteral nutrition as primary therapy compared to adults, with this approach being particularly effective in pediatric populations 1, 2
• Pediatric IBD patients require 20-80% more calories than healthy children to achieve adequate growth due to hypermetabolic state and malabsorption 2
• Ulcerative colitis is a notable comorbidity in children with primary sclerosing cholangitis (PSC), requiring surveillance for both conditions 1

Nutritional Management Algorithm

• Step 1: Perform complete nutritional assessment including serial triceps skin fold thickness and mid-arm circumference measurements—weight alone overestimates nutritional adequacy 1
• Step 2: Initiate aggressive nutritional support with nasogastric tube feeding if oral intake is insufficient, as this improves body composition and outcomes 1
• Step 3: Use medium-chain triglyceride (MCT)-containing formulas in cholestatic patients, but monitor for essential fatty acid deficiency with excessive MCT administration 1
• Step 4: Maintain normal protein intake—do not restrict protein despite common misconceptions 1

Transition Considerations

• Formal transition arrangements are mandatory for adolescents and young persons (AYP) with IBD, as inappropriate transition dramatically decreases treatment compliance and worsens prognosis 1, 3
• Differences in management between pediatric and adult care include higher use of general anesthesia for endoscopy in children versus sedation in adults 1

Chronic Liver Disease and Transplant Evaluation

Children with chronic liver disease face life-threatening complications including ascites, variceal bleeding, and malnutrition that require systematic evaluation and aggressive management to optimize transplant outcomes.

Ascites Management

• Initial therapy: Start with aldosterone antagonist (spironolactone) for clinically detectable ascites 1
• Escalation criteria: Reserve paracentesis or transjugular intrahepatic portosystemic shunt (TIPS) for ascites that compromises respiratory effort or severely affects quality of life 1
• Critical pitfall: Overaggressive diuresis precipitates hepatorenal syndrome—titrate carefully 1
• Hospitalized patients: Consider intravenous albumin with or without diuretics to improve diuresis response 1

Variceal Surveillance

• Screening endoscopy for esophageal varices is not routinely recommended in children due to absence of data supporting primary prophylactic therapy 1
• Evaluation and management practices vary widely among practitioners, requiring individualized risk assessment 1

Nutritional Optimization for Transplant

• Aggressive nutritional support prior to liver transplant improves patient and graft survival as well as neurodevelopmental outcomes 1
• Serial anthropometric measurements (triceps skin fold, mid-arm circumference) are most reliable for assessing nutritional status 1
• Fat-soluble vitamin (FSV) deficiency is common—implement dosing and monitoring protocols to prevent deficiency 1
• Parenteral nutrition may be necessary to reverse poor weight gain in malnourished children with biliary atresia 1

Disease-Specific Counseling

• Inform patients with autoimmune hepatitis, PSC, and bile salt excretory pump disease that liver disease can recur post-transplant 1
• Patients with PSC have increased risk for colon cancer and require ongoing surveillance 1
• Inform patients at risk for extrahepatic complications such as IBD about need for continued monitoring 1

Cardiopulmonary Assessment

• Cirrhotic cardiomyopathy occurs in up to 70% of children with biliary atresia, characterized by increased cardiac output, impaired diastolic relaxation, and myocardial hypertrophy 1
• Two-dimensional echocardiography is essential for detecting cardiomyopathy pre-transplant 1
• Hepatopulmonary syndrome and portopulmonary hypertension are potentially life-threatening conditions requiring evaluation 1

Gastroesophageal Reflux Disease (GERD)

Distinguishing physiologic gastroesophageal reflux (GER) from GERD is critical—only GERD requires pharmacologic therapy, while GER responds to conservative management alone.

Diagnostic Approach in Infants

• GER is physiologic passage of gastric contents occurring in more than two-thirds of healthy infants 4, 5
• GERD is defined as reflux with troublesome symptoms or complications affecting quality of life 1, 6, 4, 5
• Warning signs requiring immediate evaluation: bilious vomiting, GI bleeding, consistently forceful vomiting, fever, abdominal tenderness or distension 4

First-Line Management: Lifestyle Modifications

• Breastfed infants: Consider 2-4 week maternal elimination diet restricting milk and egg 4
• Formula-fed infants: Switch to extensively hydrolyzed protein or amino acid-based formula 4, 5
• Feeding modifications: Thicken feedings with up to 1 tablespoon dry rice cereal per 1 oz formula (increases caloric density—monitor for excessive weight gain) 4, 5
• Reduce feeding volume while increasing frequency to minimize gastric distension 4
• Keep infant completely upright when awake 4
• Critical safety point: Avoid prone positioning during sleep due to SIDS risk 6, 4

Pharmacologic Therapy

• Reserve medications exclusively for confirmed GERD after failed conservative measures 1, 6, 4, 5
• Lifestyle changes are first-line therapy for both GER and GERD 1, 6
• Proton pump inhibitors (PPIs) are overprescribed in pediatric populations—avoid using for physiologic GER 1, 6
• FDA black box warnings exist for promoters of gastric emptying and motility—use with extreme caution 1

Surgical Indications

• Reserve surgery for children with intractable symptoms or life-threatening complications of GERD 1, 6
• Fundoplication should only be considered after failed pharmacologic treatment or severe aspiration risk 6

Follow-up Protocol

• Monitor weight gain as primary outcome measure 4
• If no improvement after 2 weeks of feeding changes, evaluate for other causes and consider pediatric gastroenterology referral 4
• Upper endoscopy with esophageal biopsy indicated for poor weight gain failing initial management 4

Eosinophilic Esophagitis (EoE)

EoE is an increasingly common cause of dysphagia in both children and adults, requiring endoscopic diagnosis and multidisciplinary management including dietary intervention.

Clinical Presentation

• Adults: Food bolus obstruction and dysphagia are strongly associated with EoE diagnosis 1
• Children: Symptoms are non-specific and vary with age—feeding problems predominate in younger children 1
• Seasonal variation in symptoms correlates with higher pollen counts 1
• More common in males, white ethnic origin, and those with affected first-degree relatives 1

Diagnostic Guidelines

• All adults: Obtain esophageal biopsies if endoscopic signs of EoE present, or if dysphagia/food bolus obstruction with normal-appearing esophagus 1
• All children: Obtain esophageal biopsies during endoscopy for upper GI symptoms to diagnose EoE 1
• Children with refractory GERD symptoms: Perform endoscopy and biopsy to exclude EoE after failed PPI treatment 1

Management Approach

• Dietary modification with elimination diets (guided by allergist/dietitian) is primary therapy 1
• Topical corticosteroids (swallowed fluticasone or budesonide) for moderate-severe disease 1
• PPI trial may be beneficial in PPI-responsive EoE subtype 1
• Esophageal dilation reserved for strictures causing significant dysphagia 1

Celiac Disease

Celiac disease in children often presents more severely than adult-onset disease and requires structured transition to adult care to maintain compliance with gluten-free diet.

Key Management Points

• Diagnosis in children may be based on serology with supportive investigations without duodenal biopsy, whereas histological evaluation is always required in adults 1
• Clinical course is often more severe when presenting in childhood versus later life 1
• Formal transition arrangements are recommended for adolescents with celiac disease to maintain dietary compliance 1
• Hepatic involvement can occur—monitor for elevated transaminases and consider liver biopsy if persistent elevation 7

Complex Functional GI Disorders

Complex functional GI disorders in children require psychological management approaches more frequently than in adult practice, with increasing recognition of need for formal transition services.

Management Principles

• Psychological management is utilized more frequently in pediatric versus adult functional GI illness 1
• Complex functional disorders with significant symptomatology, nutrition support needs, and psychological comorbidity require formal transitioning to adult care with multidisciplinary support 1
• Emerging diseases like complex functional disorders are of increasing importance for transition planning 1

Critical Pitfalls to Avoid

• Malnutrition assessment: Never rely on weight alone in chronic liver disease—use triceps skin fold and mid-arm circumference 1
• PPI overuse: Avoid prescribing acid suppressants for physiologic GER in infants—reserve for confirmed GERD only 1, 6, 4
• Transition failures: Incomplete data transmission from pediatric to adult gastroenterologist dramatically decreases compliance and worsens prognosis 1, 3
• Protein restriction myth: Do not restrict protein in chronic liver disease—maintain normal intake 1
• Thickened feeds: Remember increased caloric density when thickening infant feeds to avoid excessive weight gain 4
• Diuresis in ascites: Avoid overaggressive diuresis as it precipitates hepatorenal syndrome 1